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Sellick maneuver

Sellick maneuver . Dr. S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab.DCA , Dip. Software statistics PhD ( physio ) Mahatma Gandhi Medical college and research institute , puducherry , India . Sellick -- Its all about aspiration Isnt it ?? . Aspiration.

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Sellick maneuver

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  1. Sellick maneuver Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab.DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi Medical college and research institute , puducherry , India

  2. Sellick -- • Its all about aspiration • Isnt it ??

  3. Aspiration • Incidence : 1 in 3000 • Emergency – 1 in 600 • More common in ASA IV • Solution possible ?? • RSI with preoxygenation with sellickmanouver

  4. History • Monro • In 1774, concerning the recovery of persons “drowned and seemingly dead,” the use of Cricoid pressure by Dr. Monrowas referred to as a means of preventing gastric distension during inflation of the lungs.

  5. Sellick in 1961 • In 1961 Dr. Brian Arthur Sellick • Cricoid pressure must be exerted by an assistant. • Before induction, the cricoid is palpated and lightly held between the thumb and second finger; as anaesthesia begins, pressure is exerted on the cricoid cartilage mainly by the index finger.

  6. In 1961 Dr. Brian Arthur Sellick • a conscious patient can tolerate moderate pressure without discomfort but as soon as consciousness is lost, firm pressure can be applied without obstruction of the patient's airway. Pressure is maintained until intubation and inflation of the cuff of the endotracheal tube is complete."

  7. Sellick original The maneuver consisted of “occlusion of the upper esophagus by backward pressure on the cricoid ring against the bodies of cervical vertebrae to prevent gastric contents from reaching the pharynx. Neck extended ---

  8. Full cartilage – cricoid

  9. Original sellick • confirmed the value of CP in preventing saline (run into the esophagus from a height of 100 cm H2O) from reaching the pharynx in a patient undergoing gastroesophagectomy • emphasized that the lungs can be ventilated by intermittent positive pressure and that CP can prevent inflation of the stomach during positive pressure ventilation

  10. Three fingers

  11. Indications • Prevent aspiration • Full stomach , diabetes, pregnancy, obese • Inflate lungs when unable to intubate

  12. What is the pressure ?? • The cricoid cartilage should be fixed between digits and then pressed backwards at a force of 30 newtons. • How this 30 newtons ?? • CP substitutes for the loss of tone in the cricopharyngeus, nature’s normal defense mechanism

  13. Training • Nose pain; applying pressure on one’s own nose until pain is felt has been suggested • Neck pain; pressure on one’s own cricoid that prevents swallowing 20 N • Syringe and plunger • Scales – 3 Kg • Cricoid yoke; a padded yoke conforming to the external radius of a cricoidcartilage attached to a hand-held strain gauge to assist in applying a measured consistent pressure over the cricoid cartilage.

  14. Skill lab • Cricoid pressure trainer; encompasses realistic patient anatomy with realtime feedback on technique. • The user is able to view the direction, duration and amount of force applied to the neck of the manikin

  15. Don’t confuse ?! • Cricoid pressure should not be confused with optimal external laryngeal manipulation (OELM) or backward upward right pressure (BURP) on the thyroid cartilage which is used to improve visualisation of the vocal cords when intubating. • There is no priority for prevention of aspiration

  16. When to give ?? • Moderate pressure and site-- to be done before induction • Increase pressure • Immediate loss of consciousness • Till cuff inflation • Too much pressure earlier ??

  17. What is new ?? • the current recommendation is to apply 10 N when a patient is awake, and increase the force to 30 N once the patient loses consciousness

  18. Types • Single handed A) B) • Double handed A) B)

  19. Single handed • A) Single- handed cricoid pressure: downward pressure with index finger over the cricoid cartilage, thumb and middle finger each side. • B) Single - handed cricoid pressure: downward pressure with index and middle finger over cricoid cartilage, the heel of hand over sternum.

  20. Bimanual • Bimanual cricoid pressure: • technique A with another hand behind the neck, preventing flexion during laryngoscopy. • Bimanual cricoid pressure (contra-cricoid • cuboid): with a pillow (size 27×10×5 cm) behind the hand.

  21. GER • The stomach contracts every 20 seconds with pressure increases to as much as 50 cm H2O; • It can accommodate up to1500 ml. Fasted patients may have 200 ml of gastric fluid. • The lower oesophageal sphincter (LES) is competent to about 30 cm H2O if normal. • The difference between LES pressure and gastric pressure is the “barrier pressure”

  22. GER • Cricoid pressure • Increases the tone of the upper esophageal sphincter and decreases the tone of the lower esophageal sphincter • Probable pharyngeal receptors

  23. CP and laryngoscopy • Conflicting • Correct application improves • Single handed cricoid pressure improves laryngoscopy • Wrong pressure , direction – difficult laryngoscopy • Jabalameli et al, turgeon et al

  24. Sellick and CICV • Oxygenation without aspiration • Difficult to intubate • LMA • Position pressure direction change

  25. Sellick and nasogastric tube • NG tube • Sellick originally advised to remove NG tube before cricoid pressure . • But it has been established that NG tube does not impede cricoid pressure • No problem in – 1. esophageal compression 2 stomach can be deflated

  26. POSSIBLE CONTRA-INDICATIONS TO CRICOID PRESSURE • • Trauma to anterior neck • • Unstable C Spine injury • Patient actively vomiting • risk of oesophageal rupture • • Limited number of rescuers

  27. Complications intubation is made difficult • Esophageal barrier pressure decrease • MAP and HR increase • Aspiration • Cricoid fracture • nausea and vomiting -- Esophageal rupture • 4 minutes of application of cricoid pressure at 30 newtons can lead to arm fatigue and subsequent incorrect technique

  28. In pediatrics • The application of cricoid pressure in the paediatric population has been shown to prevent insufflation of gas into the stomach during face mask ventilation

  29. MRI in 24 volunteers performed with and without CP in sniffing, neutral,and extended head positions • the postcricoidhypopharynx moved with the cricoid ring as an anatomic unit. • Termed as Cervical esophagus • Is it part of the esophagus ??

  30. Summary • Definition • Application – force • Techniques • Indications • Contraindications • complications

  31. Why not sellick ?? • A simple technique • Properly learnt can prevent morbidity • NO gadgets necessary

  32. Thank you

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